Transcript Section 21_Motivational Interviewing I

Section 21:
Motivational Interviewing I
Treatnet Training Volume B, Module 2: Updated 15 February 2008
Principles of Motivational
Interviewing
What are we talking about?
What does “increasing motivation”
mean to you?
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Motivating clients: Definition
Motivational interviewing is a directive,
client-centred style of interaction aimed
at helping people explore and resolve their
ambivalence about their substance use
and begin to make positive changes.
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In other words…
Many people who engage in harmful
substance use do not fully recognise that
they have a problem or that their other
life problems are related to their use of
drugs and/or alcohol.
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It seems surprising…
That people don’t simply stop using drugs,
considering that drug addiction creates
so many problems for them and their
families.
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However…
People who engage in harmful drug or
alcohol use often say they want to stop
using, but they simply don’t know how,
are unable to, or are not fully ready to
stop.
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Understanding How People
Change: Models
Traditional approach
 Motivating for change

Traditional approach (1)
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The Stick
Change is motivated by discomfort.
If you can make people feel bad enough, they
will change.
People have to “hit bottom” to be ready for
change
Corollary: People don’t change if they haven’t
suffered enough
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Traditional approach (2)
You better!
Or else!
If the stick is big enough,
there is no need for a carrot.
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Traditional approach (3)
Someone who continues to use is
“in denial.”
The best way to “break through” the
denial is direct confrontation.
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Another approach: Motivating (1)

People are ambivalent about change

People continue their drug use because of their
ambivalence
The carrot
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Ambivalence
Ambivalence: Feeling two ways about
something.

All change contains an element of
ambivalence.

Resolving ambivalence in the direction of
change is a key element of motivational
interviewing
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Another approach: Motivating (2)

Motivation for change can be fostered by an
accepting, empowering, and safe atmosphere
The carrot
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Why don’t people change?
What is the problem?
It is NOT that…
 they don’t want to see (denial)
 they don’t care (no motivation)
They are just in the early stages of
change.
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How do people change?
Natural Change
In many problem areas, positive change
often occurs without formal treatment
 Stages and processes by which people
change seem to be the same with or
without treatment
 Treatment can be thought of as
facilitating a natural process of change
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Faith / Hope Effect

A person’s perception of how likely it is that
he/she can succeed in making a particular
change is a good predictor of the likelihood
that actual change will occur

The effect of believing (placebo) often brings
about 30% of the outcomes of treatment

The doctor’s / counselor’s / teacher’s beliefs
can become self-fulfilling prophecies
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Brief Intervention Effect
Brief interventions can trigger change
 1 or 2 sessions can yield much greater
change than no counselling
 A little counselling can lead to significant
change
 Brief interventions can yield outcomes
that are similar to those of longer
treatments
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Dose Effect
It is reasonable to presume that the
amount of change is related to the
amount (dose ) of counselling / treatment
received
 …but this is not always the case (!!)
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It is possible that treatment adherence
and positive outcomes are related to
some other factor – such as motivation
for change
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The Concept of Motivation (1)

“Motivation can be defined as the
probability that a person will enter into,
continue, and adhere to a specific
change strategy”
(Council of Philosophical Studies, 1981)
Motivation is a key to change
 Motivation is multidimensional
 Motivation is dynamic and fluctuating
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The Concept of Motivation (2)
Motivation is influenced by the clinician’s
style
 Motivation can be modified
 The clinician’s task is to elicit and
enhance motivation
 “Lack of motivation” is a challenge for the
clinician’s therapeutic skills, not a fault
for which to blame our clients
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General Motivational Strategies
giving ADVICE
 removing BARRIERS
 providing CHOICE
 decreasing DESIRABILITY
 practising EMPATHY
 providing FEEDBACK
 clarifying GOALS
 active HELPING
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The Concept of Ambivalence (2)
Ambivalence is normal
 clients usually enter treatment with
fluctuating and conflicting motivations
 they “want to change and don’t want to
change”
 “working with ambivalence is working
with the heart of the problem”
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Stages of Change
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Activity 1: Reflection
Take some time to think about the most
difficult change that you had to make in
your life.
How much time did it take you to move
from considering that change to actually
taking action.
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Stages of Change
Recognising the need to change and
understanding how to change doesn’t
happen all at once. It usually takes time
and patience.
People often go through a series of
“stages” as they begin to recognise that
they have a problem.
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First Stage: Pre-contemplation
People at this stage:

Are unaware of any problem related to
their drug use
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Are unconcerned about their drug-use
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Ignore anyone else’s belief that they are
doing something harmful
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Second Stage: Contemplation
People at this stage are considering whether or
not to change:

They enjoy using drugs, but
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They are sometimes worried about the
increasing difficulties the use is causing.
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They are constantly debating with themselves
whether or not they have a problem.
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Third Stage:
Determination/Preparation
People at this stage are
deciding how they are
going to change

They may be ready to change their
behaviour
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They are getting ready to make the change
?
It may take a long time to move to the next stage
(action).
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Fourth Stage: Action
People at this stage:

Have begun the process of changing
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Need help identifying realistic steps, high-risk
situations, and new coping strategies
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Fifth Stage: Maintenance
People in this stage:

Have made a change and
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Are working on maintaining the change
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Relapse
People at this stage have reinitiated the
identified behaviour.

People usually make several attempts to quit
before being successful.
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The process of changing is rarely the same in
subsequent attempts. Each attempt
incorporates new information gained from the
previous attempts.
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Relapse
Someone who has relapsed
is NOT a failure!
Relapse is part of the recovery process.
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Stages of Change
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Helping people change
Helping people change involves increasing their
awareness of their need to change and
helping them to start moving through the
stages of change.
Start “where the client is”
 Positive approaches are more effective than
confrontation – particularly in an outpatient
setting.
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Questions? Comments?
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